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HomeMy WebLinkAbout0027 ISALENE ROAD � `7 �.s�le�n���, i I Town of Barnstable _ Building t Post ThiszCard So That it is Visible From the Street-Approved Plans Must be Retained on Job an this C d Must:be Kept Unfiil Final Inspection Has Been Made. Where a Certificate"of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit Permit No. B-19-4185 Applicant Name: BELCAPE CONSTRUCTION LLC Approvals Date Issued: 12/19/2019 Current Use: Structure Permit Type:, Building-Siding/Windows/Roof/Doors Expiration Date: 06/19/2020 Foundation: Location: 27 ISALENE STREET, HYANNIS Map/Lot: 267-036 Zoning District: RB Sheathing: .Owner on Record: GLASER,THOMAS A TR Contractor Name �,ANATOLI SIVITSKI Framing: 1 Address: 806 HEATH ST Contractor License: CSSL-106040 2 CHESTNUT HILL, MA 02167 i'T� " ° Est. Project Cost: $30,000.00 Chimney: Description: siding,doors roof Permit,Fee: $ 153.00 Insulation: Project Review Req: . Fee Paid:; $ 153.00 Date. . 12/19/2019 Final: Plumbing/Gas Rough.Plumbing: �. ,,Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months`after'issuance. All work authorized by this permit shall conform to the approved application and.the�approved construction documents for hich thi w s permit has been granted. Rough Gas All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws.and codes. This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open forpublic inspection for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of five Call inspections Required for All Construction Work: Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Application number �r.../... (.�............ Fee............/... 3.................. ................. ' BUILDING DEPT Building Inspectors Initials....... DEC 19 2019 Date Issued...............�.�.��.`..�:... ................... TOWN OF BARNSTABLE Map/Parcel...... . .�....... 3K) TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 27 Isalene Rd Hyannis NUMBER STREET VILLAGE Owner's Name: Thomas Glaser Phone Number 617-566-0004 Email Address: tag21000@aol.com Cell Phone Number Project cost$ 30,000.00 Check one Residential X Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Siding © Windows(no header change)# 5 ,. Ins ulation/Weatherization Doors(no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 Iayer of shingles) Construction Debris will be going to S&J Exco Dennis CONTRACTOR'S INFORMATION Contractor's name BelCape Construction, INC, Home Improvement Contractors Registration(if applicable)# 182457 (attach copy) Construction Supervisor's License# 106040 (attach copy) Email of Contractor belcapeconstructionr7a gmail.com Phone number 508-685-9720 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY/S/N A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A`PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one:this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with.the location(s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side, HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date - LICANT'S SIGNATURE Signature Date 12/19/2019 All permit plications are subject to a building official's approval prior to issuance. Curtains, drapes and window and door treatments may need proper reinstallation.or replacement by customer due to sizing on any window or door replacements:and. is not included in jobs contracted with BELCAPE CONSTRUCTION,.:LLC Any alteration or deviation from..ab&e specifications involving extra costs will;be.executed only upon written orders and.will become an extra charge over and,above>the estimate.All agreements contingent upon strikes,accidents or.delays beyond our control.Owner to carry fire,tornada.and other necessary insurance upon above work. Workmen's Compensation and Public:Liability Insurance on. above work to be.taken-out by BELCAPE'CONSTRUCTION,LLC.No.hen or ecufity interest will be placed on the residence: as a consequence of the contract. Owners who secure their own construction-related permits or deal with.uriregistered contactors will be excluded om access the guaranty fund. This Contract not valid unless.,signed by Company Representatiy , Acceptance of Estimate The above-prices, specifications and conditions are satisfactory and are hereby. accepted. BELCAPE CONSTRUCTION,LLC is authorized to do the work.as specified, Contract-total: $ Aaaid d'`" ff acceptable, initial°here: Payment will'be made as:such: 1'Deposit 1/3 $ `d�a o'. 1 .1D Start day payment 1/3c $` d, ocs o Upton completion 1/3 ' $ oac Date: gnatures: Note:No w6rk'shall begin pribf-to the signing of the contract and transmittal to the owner of a copy of such contract. You,the buyer may cancel°this transaction at:;any timeprior to midnight of the third`business day afterahe;day o£:this transaction. Accepted By: 6� `s. . . Date: THIS PAGE IS PART OF.AND IN CQNFORlUTANGE WITH PRQPOSAL: 271sale d Hyannis . -, Office of Consumer Affairs and Business Regulation One Ashburton Place Suite 130`1 Boston, Maach use tts 02108. Home amprovem(i;t ractor Registration Type LLC Registration: 182457 BELCAPE CONSTRUCTION LLC. co 42 W O.OQBURY.AVE to Expiration: 02/05/2020 HYANNIA,MA 02601 i d a Update Address and Alum Card: WA 1 A 20M-05H Z Office:of Consumer Affairs&Business Regulation HOME IMPROVEMENT.CONTRACTOR Registration valid for individual use only c YPE:LLG before the expiration date. If found return to: R ish�tio 901ration. Office at Consumer'Affairs and Business Regulation. ; 0PJ05/2020 10 Park Plaza-Suite'5170 BEICAPE COS;} " µ r ` Boston,.MA-02116 , i t ARLOU DBANIS r t 0WOODBURYAVI< ds HYANNIA,MA 02 1 ' of valid;Without signature Undersecretary .�, t s °K! r • - 1 4 a R i w 1 +r y r X ; Co rnmonweath of Massachusetts a {. Division of Professional L:icensure � � i uX Board of Buildings Regulations and Standards ! !Spa 'If 05/14/2020 yireS. y r! AIVATOLI SIVInTSKI -;R �4 27 MILL PONCE-RD ` t WEST" YA�tfVl01�!$TH m-A�0267S Commissioner C4 r Yn y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kv . 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): BelCape Construction Address: 42 Woodbury ave City/State/Zip: Hyannis, MA 02601 Phone#: 508-685-9720 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓ I am a employer with 3 4. I am a general contractor and 1 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.: required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.✓ Other Roofing, Siding comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: AmGuard Policy#or Self-ins.Lic.#: R2WC085768 Expiration Date: 02/12/2020 Job Site Address: 27 Isalene Rd City/State/Zip: Hyannis, MA 02601 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and ins an enahties ojperjury that the information provided above is true and correct Signature: Date: 12/18/2019 Phone#: 50 85-9720 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: . . .. . ,. . -. DATE t RL7 . . CERTIFICATE OF LIABILITY:INSURAIdCE ov�3r2o1s THIS CERTIFICATE IS ISSUED"AS A INATTER OE INFORMATION ONLY-,_:A-_ AND CONFERS NO RIGHTS"UPON THE CERTIFICATE HOLDER;_THIS - .C1. ERTIFICATE DOES NOT-AFFIRMATNELY OR:NEGATVELY AAAEND, EXTEND Ott;ALTERTNE COVERAGE`AFFORD® BY THE:POLICIES __ ',, BELOW. THIS CERTIFICATE OF"INSURANCE DOES NOT CONSTITUTE A',CONTRACT BETWEEN THE ISSUING INSUF;t*S);•`AUTHORQED REPRESENTATIVE OR-PRODUCER,AND'=THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INS URED,;the poRcy(les)must hairs ADDITIONAL INSURED _' - -_i- or11..be ernlp-, '_ If SUBROGATION IS WAWED,enb)ect to-the terns anM conditions of.' poo*'certain poll�es may require an endorsemern. A`sfatiimerrt on this iertiRcatie dos not confer ri hts to ftie certJficate holder in Ifee of such endorsenrerrgs. PRooucER ':Victoria Slfarapo� ALD_Insurance Agency InC 80A Brighton Avenue: 617 787-7877 " F 817 78T 7876 Allston,MA 02134 E NAIL . ircsu` A+rormBvGcovERAGE :` w�s Bin 'ATLANTIC CASUALTY INS:t� ; lw-.- : .-. twsuRED' ' .Betcape Construction the : . AMGUARD INSURANCE COMPANY;, 42390 s 42`.1Noodbury Ave e Hyannis,MA 02601 tNsura3ee 3" � D. } IN8URERE. '` - RER F. COVERAGES CERTIFICATE'NUIMBER. r' '' .REVI$ION.NUAABER. 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L�1..��Ir',.�.'-,,"'''r;.­'.��­.r.`.::._�.r,_. �:.;,'r;L.,�--.­.,-r�,....:;-�:-.l,�,'.'�L�L"�.:..�.rI- CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,•THE`INSURANCE AFFORD®B1!THE'POLICIES:OESCRIB®HEREIN IS SUB IECT TO ALL THE Tt49S EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY:FIAVE 8E[7d.REDUG®'BY,PAID CLAIMS. .. BusR _ .,_.,: TYPEOFI WRANCE' - 'POUCYNt1lABER '' . . .POLICYEFS..;:POLICY.t]fP ;' `tltdtl;i _ A colarre:aALOMasALUMLm y L281002952 02i06f O%1 2JOBi2M EAci+occuRi:EwcE, .' s ' 1,000,000 r CLAIMSSMADE ©OCCUR k g 100,000 _ MED E7�Arry are' a 5000 PQtsor�ALs`ADuiwuRY. a 1000,000 GB&AGGREGATE UMR APPLIES PEt2 GENERAL AGGREGATE . 2 ON O00 POUCY,�J�Ci:al. ©LOC s PRODUCTS-COMPIOPAGG: LS 2 000,000 OTHER:' ' S . At T=OaBJ UA9tUT. . `;. .N . ANY AUTO �t b BO'I :IIWRY(Perpmsrn) .:S OVYN®` SCHEDUI t� AUTOS ONLY AUTOS ' BODaY7tdIURY(Paaodd�rt) :S HIRW : NON•OYIMFD 2 PROPERTY DAMAGE AUTOS ONLY AUrOSONLY UMBRELLA LtA6 ,. -- ,. -.. OCWR - EACH OCCURRENCE `S Ct/10NS MADE " � AGGREGATE :: S D RETENTION& •::• S B R2WCA85788 02J72J2019 Q2M=020 TttTE _ APIY PROPRIETORIPARiN /EXECIItIYE _. N/A EL EAg1 ACCIDENT S 1 OOD 000 OFFICER/MEMBFJt E1(CLUDED? (ManEatory 1n N10 . . Ir res,le�riDs urm� , E L DLSEASE EA EMPIAYEE's 1,000,000 DESCRIPTION OF OPERATroNS eetow - E L DISEASE-.POLICY LIMIT,'S. 1,OOD- . :k ' VZSdR TON OF orerAndhm t orr►tronrs,V&=Es WeoRbaot Aaaworiai;Rea�i�so►redu>a�ias�+eeattaaneaH�espaee►s�aqutreai . . . , . i, CERTIFICATE<HOLDER CANCELLATION :' SkOt1LD-ANY OF THE ABOVE DESCRIBED POL I BE CMtCEL1 ED BEFORE '.. h }s * i 7ItE_ EXPIRATION-'DATE,THEREOF, :NOTICE ";WILL bBLNERED W x ACCORDANCE WITH THE POLICY PROV(StONS s " 4 f f :' :< r' - AlT1i40FBZID REPRESENTATIVE a.. x " y.i Y a H 01llm- 15 ACORD:CORPORATION`All rights reserved. s ACORD 25(2046/OS) %:r The ACORD name and logo are egi�tered marks of ACORD . - :-P',: . .• '} ' - Tow of Bftble = J'1�Q � �� Expnzs6fm�isureaete 4 atoq Sefl kees Fee NAM Richard V.;scali,interim Director AFR Building'Division FE8 ADO Tom Perry,CBO,Building Comm'z f �f�N® 9?o'b► 200Main S`aeet Hyannis,MA 0?601"" F 8ryR , irmto,-mbarnstable.ma.us l u�'TA Office. 50$-852-g038 Fa�c: �790-62�0 EMMS PERMT APPLICATION - gMENTU. ONLY Map/parcel Number Q670 // Not YaMd whliowRedX- -Press lWrint 3 to � Prop&6rAddress A4 a_ - or residential Value'of WorkS IS,�3 Minimum fee of 535.00 forwork imderS6000.00 Owner's Name&Address_Q2Iq/L am C, 1,q�flk- ��len c� W^/JltiitP/,fdot. IdA oZ67Z--- Contractor's Name_ �al.ir_Q;nr a s / � -ton n i cnn i eIephone Ivumber(�O11T_?_k-cI kW home Improvement Conttacior License (if applicable) /7 q 5- Email: Construction Supervisor's License A(if applicable) OR Lzf) GgWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor I-am the Homeowner I have Worker's Compensation Insurance Insurance Company Name A rc,.,n G yr Ins o tc,Y1 Workman's Comp.Policy Copy of Insurance Compliance Certtfcate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(snipping-old shingles) All construction debris v-411 be taken to ❑Re-roof(hurricane named)(not stripping. Going aver-. ... w sting layers ofroof) Re-side �L Replacement Windows/doors/sliders.U-Value . 3 C (mwamum 3' of wind of doors: _ ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required Separate Eie&ical&Mire Permits required. *WhrAe required: Emamw o€this pennn does not exempt compiiance with other tmvndepamunt rewlations,i.e.Histoew,Cowervet M etc. `Note: PropertylPmer mi&size Property Own or Letter of Permission. A copy a the Home Improvement Contractors License&ConstractionAppervisors license is � regan:ed. 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Yaa artz'eudd id to a copy of tins st the.time yva dun af.ang tip pay aff the fall aepwid 6 1: =des Ah d�oenan4 aiad is$o slaing Yaa may bd entitled i y reety.e a pasdal.1 e:Ibctts or 1h@ bu ins.end!Inairaaot eha es l solivr no r+g t to t�arpows ti�••,,�ee. or conusuk army f�reaah of'the Apace to rtposaetia 6oO purci;uueed ondar this ent.�5�lEoainap:eaia fbaa lees..$:, if it cot$ o;meted of t$c—min olHee or a o�ie al'ibtri. ll Y ltiu aa6yje Ilia self at�1s or PQer mal,u crrtflee esT�raneEiafdca s$e:wa k0�+;aee�eatby tatered ae a eisd ,iih,cL.1�aII 6e tecl aotlAter than+mdnig -• a the ibird calendar d9ty if-the lffl�da'-- tha ilge�cmenE��cJi:ding'9anday aid inyrfsaltilep an Naiacb regular mailiirsl4 es tare totiO G•See t c.stoe �ti�iglutg +tii°of noel tfon fnrn Bor as eilgla�gatlon 6f 6nyrri,i rihl is '. .'' Tr the:ltkcde:Td�sd,Caa,Er.�ctiora �hntx`E+�artl't (,Ba�ar'a� t •$��i5'�T�P�. - Itsmaitia]lsg 9v�thlJNi�l, ngland, YA ... ose if,>'�0jb MAY CANQli;TM TRAN MON AT ANY PRIOfl i�o&3��uc}1T OF, .TMD' HUSPH�SS ilAiY gpTg�.T Lti11 _0,THE S IrRANS�QTiUI+?. ATTAt I D 1 QTfCIEH Ok'Gi%N�s r a°rEQIY g D ;ti Sc ;. .. ._ rye, .*Qk�7Z.Y �9. 10_'N'Q.�ial+?'' - _ - r r.,rerCg C4NCE t ors CANCELLA'noN- p�. Y y•! 's u f K fees.of Trartsa an t 6'Yap, may,eaireef r Dace;oF Transaction Q / lrou qv" cancel' tf►is trans&Ct6®r4.aritltart piieaisy or o6ii ett 'wCtlilm this trarua4c#.oe.,gr out any penalty op obi � vritftlra' ttiree htayy6!*s fty';,M the phare;date.it r..i caeu�B, bosihM'"S fig M tte 5l - &bpL if ;cancel,aatli.. property:tiradetl.'n,My pay'txnts:rr a iviP`.yiati ii�iar tit®°� P�PRi i�F try o+,any,paij�rneiat$"mati� bfi�nc►u,;undW,tliOr Co. .ast ar Sales artd,aP+1►nm able t[ratetnn�nt e�es�edl:I! �Efaet.drt Stit;.�rld � ok�ahle ii.�{�rmerik e�a[ented'' by Yaa vvlll be i�dtmorf:w+own ten hussy ft .flolkiiwing F by y�M9 bo_wed vl�ftfiin ttn b'usi'n�.d�fa9owln� ( ! t158-seller of ... r CWCCIIe *n notk%WW a" nk1s, file. nCfer,`af Yo'� Saneell 'on trot er 2M'MT senuity 6d,e est,arras ojottt_ot,the"trail"C66A 1wilfi he- t =Vvy 660i t ceshi,g out,d( dte'irai„aetton vAlf-be neele4.lf fence,, u it me&®atrailablo tom Se[ler, c cclOd lCYou stinSeii�vav rr3uiEmako.tatiiifa a bls the Shcvr atY"r MCe,ins �ji t9 gaol'uulKlldvf�miwhen•j' atyouu R"dence�ie su �t�tetFiall�i al govaf condeti'ott esvMFhsn rem i I 'X goodb delrvared tv X under then Ca rst:t or f rece3ved'.an1r'goods.�alt rod tea yQa uF►Eler ifila Conttaat:ar la} s1K y rieggg3fa 4 stfJ�3a�eor my m yytt.aitth.cv+nFbri't+fttitlto in98ct�tlotra oi; tli.Salfa:r iht rem)tt s�dpriter,t o t{rni good the the Seger rein ag tte.return ahipnunt of tl,e;grinds at t4ier . Seiler s oXPOM*' � rlsk.sf yeu do."Utfe-ti die:goods ai!alt 14- 1-11;-A��nbe ,Q asks CFyou do malls the,goads saih&4. trr the'S er and.the Sifbar dv®wor p»ek:;thrm.up,wiehdn. oo tits 8ofl'@r atld tlia 5effer does not pl't k•the�n uiiwitltin j des of tliri data.of ellatfon,yet r+ t,r tslty or°I' ei 7F days off:the do"of, ceiiatiorr,`ybu iftly retsiei;i►a^. 06 the gcrod:without eral.fui r obilgatzcn:If you L r1i- apes.of the gaods.%Wthout ai 't further obt4p k,oar If You ; fasU to,Halo ttC goods.alFWIA1,e.bo the"Sei_ler,of if*U alSree..3 fail to nii6 the good*arait�ilbie tv the Sellieri or ifyou age�a to r .zlhe gfiod3 to the Shcea a�tid fag to do so,then you'� to returnth thplki,d e:goods is e Sr a ;fAif doso,a""you remaon liable for Qerl9ormxil� of aiI phliiptions udder the { reinaln labla for �rfbnntat5.te gf all o6Ggoticns under,the: Contract.'ii?cancel d►G3 crwnvaekrer+y ens ar del sfglrsd �i r6ractvTo carmei tfies trartsultor%vital or delhit' tiger . and"dlifesl copy'ad this eartoeli n nodCaE or,a"-0.ter and.d'atetl ea�r.of this tariaellbtion notice or asuy.ofAer; wfcet�crit+adze,arsertdatflCooftsoallty Mderaenof 11 vyrrfennofEae,nrsanalateiegrarettioReriewa16y1ndwsefpof Sou tali NOW Englsrt Alh[On Lf Rl IY2Ii66,, 1, Southem Neu fatgland'at Z6 AIM' Rag I Pj NOW NOT LATERTt1AN MIDNfG1TT ,'..- NO7T'!•ATIERT14AN MIDNIGHT t7F'.• fbER BY CAIhiC:'ElTW15T11A1fSANION; FHEf(EBY CANCElLTHiSTRANSAC'fJON� - ' i M{r Flw3le:" pMr. • �CR'ima+ Pelitt'Fi3mi- �b :CvFry w�,t .: end eiw ;gldw &g.C,* Oftk' Southern New England windows d.b.a Renewal by Andersen of SNE Massachusetts-Department of public Safety Board of Building Regulations and Standards Constructio/n��'Sup�e�r�visor 1 - 07 BRIAN D DENNLWN 7 LAWM POND CIIt� Charlton MA 8107 ` t Commissioner 091081mis A ; ����GL'• (��C�fiG71ZT'�!'t•%L'f? �t,-C�nn 8'4C/.�IJfLGyla'C�IG•'��1• Office of Consumer Affairs and Business Regulation gf 1 10 Park Plaza=Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Rgtstra8on: 173246 Tvpe: LLC Expiration: 911912018 Tr; 251W SOUTHERN NEW ENGLAND WINDOWS LL MATTHEW ESLER -----—----- ---._.._. 26 ALBION RD _-. — ---- - -- LINCOLN,RI02865 - - Update Address and renrro card.Mark reason for e6ange. Address I7 Ronewal 0 Employment ❑Lost Card - �, <>?ife�iysm�n !A6 r�ci{/avavLc�C 9` 6'rK.C*fC" oaumcr Athira&Bemoan Rtphfion License or registration valid for indiridul use only IMPROVEMENT CONTRACTOR heforetheexpirationdate.Iffnandrdnrnto_ 1732" Typo: Oftice of Conmmer:Atmirs and Hostoea Regulation 0on: .8ltOrT018 LLC 10 Park Plaa-Suite 5170 fi Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. I RENEWALOYANCERSCN - I( MATTHEW ESLER - - 26AL8IONRD �VI - LINCD:N,RI 02865 Uadeaamnp N01 r i> out ligaeture The Commonwealth of Massachusetts Department of Industrial Accidents 93 Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 A, -www mass.gov/dia - Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (susiness/organizatiot>/tt►dividuat): SOUTHERN NEW E.NGLAND WINDOWS Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 Phone#:401-228-9800 Are you pn employer? Check the appropriate box: Type of project(required): I.FM1 I amN a employer with 20+ 4. Q I am a general contractor and I 6 New construction employees (full and/or part-time).* - have hired the sub-contractors 2.❑ I am a sole proprietoeor partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers°_. 9 Building addition > < , comp.insurance.:[No workers comp. insurance 10. Electrical repairs or additions required.] 5. We are a corporation and its ❑ p 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.[] Roof repairs insurance required.] t c. 152, §1(4),and we have no Window Replacement q ] employees. [No workers' 13.� Other comp.insurance required.] *Any applicant that checks box 91 must-also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARGONAUT INS. CO. _ Policy#or Self-ins.Lic. #:WC 928058352394 Expiration Date:8/21/2016 Job Site Address: 0?7 �4SA_L:Ekt"' 2aP. City/State/Zip: 1k).1666Pfi/ Or Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A.o�'IVIGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for' surance coverage verification. I do hereby certi under the ' s and penalties of perjury that the information provided above is true and correct. r Si ature: Date: d'/L Phone#: 4012289800 . i Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r SOUTNEW-01 SHETTYSHT —OATE(MIWDD/YYYY)-.-- CERTIFICATE OF LIABILITY INSURANCE. - - W1912015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CE^C W81is Certificate Center Willis of New Jersey,Inc. PHONE ;(8T7 945 7378 No:(8ti8 46T-23T8 c/o 26 Century Blvd P.O.Box 305191 ADDRESS;certificat9S Wi1lls.com Nashville,TN 37230-5191 INSURERS AFFORDING COVERAGE NAIC tE INSURER A:SelectIVO insurance Company of Southeast 39926 INSURED INSURER B:OneBeacon Insurance Company 21970 Southern New England Windows LLC INSURERC:Argonaut insurance Company 19801 DIBIA Renewal by Andersen INSURER 1) A= -26 Albion Road 1� Lincoln,R102865 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS; EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE CY EFF POLICY EXP LIMITS LTR D WV POLICY NUMBER D MIODNM A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAMS-MADE In OCCUR S 2029459 08/10/2015 08/10/2016 PREMISES Ea ocwrrence S 100,00 MED EXP(Any one Person) $ 10,000 PERSONAL&ADVNJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,00 POLICY 0 JJECT 0 LOc PRODUCTS-COMPIoPAGG s 3,000,00 OTHER s AUTOMOBILE LABILITY Cho aMBI Eo SINaE umiT g 1,000.00 A X ANYgNTO S 202USS 08/10/2015 08/10/2016 BODILYINJURY(Puperom) S ALLOWNED AUTOS SCHEDULED BODILY INJURY(Pera edmg) $ NON-OWNED AUT -PROP RO DAMAGE $ X HIRED AUTOS AUTOS AUTOS Per accidentt $ X UMBRELLA LWB H OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIA 3 CLAIMS-MADE S 2029459 0811012015 0811012616 AGGREGATE $ 5,000,00 DED I RETENTIONS S WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNERIEXECUTIVE Y� NIA 0000068028 0812112015 08/21/2016 EL EACH ACCIDENT S 1,000,00 OFFICERIMEMBER EXCLUDED? 000,00 (Mandatory In NH) EL DISEASE-EA EMPLOYE $ , U yes.desrnbe r ' DESCRB"TIONOFOedderPEFWTIONSbelow EJ_DISEASE-POLICY LIMIT $ 1,000,00 C Workem Compensation WC928058352394 08/2112015 08121/2018 See Attached J DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached it mare space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, JQMCE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE vidence of Insurance 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD